- Heroin is shorter-acting but Morphine, Methadone, Fentanyl, all longer-acting
How long do I watch after Narcan?
(One approach: use 2-hour mark and Christiansen rules. Counter-argument: These rules were developed in the era before higher-potency narcotics were more common.)
CHRSITIANSEN, Academic Emergency Medicine 2000: Developed a 1-hour rule where felt safe to DC a heroin overdose once back to baseline with normal vitals. (One of those patients observed to the 2-hour mark actually returned dead 7 hours later, and may have again overdosed).
CLARK et al. Emerg Med J 2005: Notes 60-90 minute half life of Narcan, reviews literature, agrees a 2-hour or at least 1-hour observation period reasonable and safe.
BOYER, NEJM, 2013. Written by UMass's own resident tox expert and ED physician. Recommends 4-6H observation period (a relatively standard recommendation, without a strong evidence base behind it.)
[ ] Naloxone 0.4-2 mg IV (or as low as 0.1 mg, titrated). Onset 1-2 mins, duration 20-90 mins
- titrate to respiratory. Higher doses for Methadone, Lomotil, Fentanyl
- Watch for opioid pulmonary edema s/p Narcan
- Narcan 2mg + 3mL NS in neb has a slower onset, better tolerated
- Narcan gtt: Use 2/3 of successful reversal dose, per hour
[ ] Activated charcoal if symptomatic o.d., Tylenol levels
Naltexone (Vivitrol): a once-monthly IM treatment that reduces opioid cravings, usually given after a detox program to prevent relapse.
Buprenorphine/naloxone (Suboxone) works similarly